The role of the paramedic in the UK has evolved over the past 10–15 years. Paramedics now practise as autonomous practitioners using complex problem-solving skills and make clinical decisions. This runs alongside an increase in responding to mental health emergency presentations in the community.
Paramedics are often patients' first point of contact during mental health crises (Shaban, 2006; Elliott, 2013; Rees et al, 2014; 2017) because emergency services are available 24/7 (Clarke et al, 2014). Accessing emergency services for mental healthcare now accounts for approximately 10–15% of patient contacts (Clarke et al 2014). Therefore, paramedic students need to gain insight into caring for and treating someone in mental distress and it is important that they experience working alongside mental health practitioners.
Paramedic training focuses predominately on trauma and emergency physical healthcare rather than on identifying symptoms of mental health deterioration (Elliott, 2013; Rees et al, 2017). Paramedics recognise there is a need for additional training in communication skills, particularly when encountering patients who require mental health care (Rees et al, 2014). Mental health training is provided during a paramedic's degree; working alongside mental health practitioners in mental health settings to enable the student to apply classroom education to practice would help to strengthen skills and knowledge.
The literature on mental health training has, overall, focused on qualified paramedics. For example, Elliot (2013) recommended that paramedic staff are trained to develop reflective practice, skills in clinical judgment and knowledge of mental health services, and be able to recognise mental health crises. Rees et al's (2014) systematic review of mental health training provided to paramedic and emergency staff identified outcomes of improvement in staff knowledge and confidence associated with fewer negative attitudes, specifically in relation to self-harm.
Confidence in knowledge and the ability to support patients are key to forming positive attitudes and providing high-quality care (Clarke et al, 2014; O'Hara et al, 2016). Across the literature, it is widely recognised and recommended that emergency staff, particularly paramedics, receive mental health training (Shaban, 2006; Elliot, 2013; Clarke et al, 2014; Booth et al, 2017; Rees et al, 2017).
However, the evidence on the outcomes of training programmes is limited (Michau et al, 2009), as is literature that explores the influence of mental health training and practice on paramedic students' understanding of mental health. This is what prompted the present pilot scheme.
A south of England mental health trust, in conjunction with one of its local universities, decided to pilot a paramedic insight placement. The aim was to find out if an experience of working with mental health teams would give paramedic students an understanding of patients with mental health issues that may not be achieved through classroom-based training alone.
As part of this pilot experience, evaluation questionnaires before and after the insight placement were used to elicit whether students' understanding had changed after the placement. This evaluation was used as part of the usual evaluation process for placements. Even though an insight placement approach is used in some universities, this was new to this local university partner.
Evaluation
Participants
Forty undergraduate paramedic BSc students from one cohort at a university in the south of England university attended a 2-week insight placement across a range of local trust mental health services.
Insight placements were provided in: crisis resolution and home treatment teams (CRHTs); assertive outreach team (AOTs); mental health liaison teams; the mental health rapid response team (MHRRT); and a triage team in a local accident and emergency service.
In these services, paramedic students would meet mental health patients in distress or crisis and experienced practitioners who staff these services, observe psychology-based interventions applied to these situations first hand and experience multiprofessional working.
Design
The before-and-after insight placement evaluation questionnaires consisted of: a pre-insight placement evaluation questionnaire with 19 items, including: background information; previous mental health training and experience; and current understanding of mental health. A short Likert scale was included with mental health statements that related to the role of the paramedic (Appendix A).
Students were invited to complete the post-insight placement evaluation questionnaire after their placement (this omitted the background information questions). They were asked to complete the Likert scale questionnaire again so that the results of both could be compared. Two additional items were included in the Likert scale: ‘My mental health insight experience has increased my understanding of mental health services’ and ‘My mental health insight experience has increased my understanding of the needs of the mental health service user’ (Appendix B). These were added to elicit the students' general understanding of their placement.
The Likert scale for this evaluation was informed by a validated questionnaire by Emond et al (2015), who researched the mental health perceptions of fourth-year paramedic students in Australia.
Method
The paramedic students were met by members of the trust's nurse education team during one of their study days.
Students were provided with the details of the insight placement, including that it was a new placement experience for the programme, which informed them of the different services they would experience, what to expect from attending the placements and details of the evaluation.
The questionnaire included a disclosure statement informing students that their data would be kept and used anonymously as part of usual evaluation data collection and analysis. No participant names, addresses or other personal details would be disclosed. Ethical approval was not required as the students were consenting to an evaluation, which is usual for placement experiences. Completion of the questionnaire was optional.
Results
More than half (65%, 26/40) of the students stated that they had had no mental health care training prior to their paramedic course. Those who had received mental health education received as little as 4 hours, with the average being 6 days. This education had taken place from a month to nearly 2 years before training.
The majority of mental health experience was gained from taking part in skills-based training and workshops (37%, 7/19) and attending lectures or talks (32%, 6/19). The minimum experience reported was from web-based training (5%, 1/19) and training in a clinical setting (5%, 1/19). Two students out of 19 (10%) selected ‘other in-depth training above 4 hours’.
The students were asked about the area of mental health covered by their education. The majority (25%, 10/40) stated they had trained in subjects such as depression or anxiety. The second most common area was information related to definitions of terms and case studies (22%, 9/40). The topics where people had the least experience were in making referrals (5%, 2/40) and in mental health assessment (8%, 3/40).
Students were asked whether they had gained any experience in a mental health-related setting. Out of the total experiences listed, working in a hospital and in a care or nursing home were the most frequent areas where trainees gained mental health experience. The majority of experience (43%, 15/35) was gained in dementia and Alzheimer's services.
Both the before-and-after questionnaires asked students about their understanding of various mental health concepts and their agreement with statements relating to the paramedic role.
In the additional post-placement questions, 80% of the students who responded (12/15) said they either ‘agree’ or ‘strongly agree’ that the placement increased their understanding of mental health services and mental health service user needs. All the post-placement results showed that students had greater understanding of all mental health concepts mentioned, as the majority of participants responded ‘agree’.
Limitations
The return rate of 26% was small so cannot be said to be representative and this inevitably influences the reliability of the findings and means the findings cannot be generalised. The evaluation was completed with one cohort in one university so the results cannot represent all paramedic students. A larger study would focus on ways of increasing the return rate. To improve the survey return rate of future cohorts, the evaluation team could increase contact with the students as they experience the insight placement.
However, the data that were analysed have highlighted the importance of a mental health practice experience as part of paramedic training. They also provide the nurse education team who support the paramedics on their insight placements with a platform for further discussions with the students and programme leads about mental health-focused programme content.
Other limitations include the lack of a control group, which could have been possible with a larger cohort. The authors were aware from the pre-placement data that several students had experience of mental health education, although the number with practice experience appeared to be insignificant. However, as this experience did not take place between when the pre and post evaluations were carried out, this would not have influenced responses to the Likert scale.
The limited availability of literature, which generally focused on self-harming, could not be used to underpin the direction of the pilot evaluation.
As part of developing a larger study, the questionnaire could be revised to exclude statements that are not neutral; in addition, statements could be made more explicit to avoid students agreeing to concepts that could be perceived as vague.
Discussion
This was a pilot insight placement evaluation carried out with the intention of using the data and learning to inform future evaluations. This experience had not been provided before in the trust and there still is a dearth of UK-based literature to inform these learning experiences, particularly studies that focus specifically on the NHS.
The trust was able to provide a number of varied mental health service experiences, many of which involved working with patients in distress and crisis. Paramedic students, unlike other care trainee professionals generally, spend much of their working time in the company of other paramedics so here was an opportunity not only to find out about mental health services but also to work in a multiprofessional team. It could be suggested that the experience of working alongside mental health professionals would help ‘myth bust’ ideas about patients with mental health issues.
A positive gain for the trust was the anecdotal feedback received from teams about reciprocal learning. This feedback suggests that there is potentially much for mental health services to gain from having a paramedic student on placement.
This pilot has highlighted the tentative gains from having a 2-week insight placement and it is a model that is sustainable for the trust. Since completing the pilot, the trust has been working with another university to provide more placements for paramedic students, with a plan to support a cohort of approximately 35 more students. This could help to further develop the evaluation through the use of a cross-site comparison insight placement evaluation.
Recommendations
Any recommendations can only be tentative at this stage as this was a pilot evaluation study which needs to be developed further with a revised questionnaire and include the new university partner so data and conclusions can be compared. Ethical approval would be sought if this pilot evaluation was extended into a larger study beyond the remit of the usual evaluation processes.
Other recommendations for consideration are:
Conclusion
Using this pilot evaluation, the aim was to find out if students who experienced a short mental health placement increased their understanding of patients with mental health issues. The tentative conclusions are that this insight placement increased paramedic students' understanding of mental health services and their patients' needs, and that the students also gained a greater understanding of mental health concepts. Being in direct contact with mental health colleagues also appeared to reinforce learning about mental health services, multiprofessional working and the patient experience.